Background: Patient-centeredness is necessary for quality of care. Wide-spread incorporation of patient-centered practices across the health system is challenging in low and middle income countries (LMICs) given the complexity of scarce resources, competing priorities and rapidly changing social, economic and political landscapes. Health service managers and policy makers in these settings would benefit from a framework that allows comprehension and anticipation of forthcoming challenges for optimizing patient-centeredness in healthcare delivery. We set out to formulate such a framework, based primarily on analysis of general patterns of healthcare system evolution in LMICs and the current literature. Discussion: We suggest that optimization of patient-centeredness in LMICs can be thought of as occurring in four phases, in accordance to particular patterns of macro transitions. Phase I is characterized by a deeply fragmented system based on conventional clinical approaches, dealing primarily with simple acute conditions. In phase II, the healthcare systems deal with increasing chronic cases and require redesign of existing acute-oriented services. In phase III, health services are increasingly confronted with multimorbid patients, requiring more coordinated and integrated care. Complex health care needs in individual patients are increasingly the norm in Phase IV, requiring the most optimal form of patient-centered care. This framework helps to identify and map the key challenges and implications for research, policy and practice, associated with the transitions ahead of time. Summary: We have developed a framework based on observed patterns of healthcare and related macro-transitions in LMICs. The framework provides insights into critical issues to be considered by health service managers and policy makers.